J Korean Neurosurg Soc.  2021 Sep;64(5):791-798. 10.3340/jkns.2020.0346.

A Prognostic Factor for Prolonged Mechanical Ventilator-Dependent Respiratory Failure after Cervical Spinal Cord Injury : Maximal Canal Compromise on Magnetic Resonance Imaging

Affiliations
  • 1Department of Neurosurgery, Trauma Center, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
  • 2Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
  • 3Department of Neurosurgery, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
  • 4Department of Neurosurgery, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea

Abstract


Objective
: The period of mechanical ventilator (MV)-dependent respiratory failure after cervical spinal cord injury (CSCI) varies from patient to patient. This study aimed to identify predictors of MV at hospital discharge (MVDC) due to prolonged respiratory failure among patients with MV after CSCI.
Methods
: Two hundred forty-three patients with CSCI were admitted to our institution between May 2006 and April 2018. Their medical records and radiographic data were retrospectively reviewed. Level and completeness of injury were defined according to the American Spinal Injury Association (ASIA) standards. Respiratory failure was defined as the requirement for definitive airway and assistance of MV. We also evaluated magnetic resonance imaging characteristics of the cervical spine. These characteristics included : maximum canal compromise (MCC); intramedullary hematoma or cord transection; and integrity of the disco-ligamentous complex for assessment of the Subaxial Cervical Spine Injury Classification (SLIC) scoring. The inclusion criteria were patients with CSCI who underwent decompression surgery within 48 hours after trauma with respiratory failure during hospital stay. Patients with Glasgow coma scale 12 or lower, major fatal trauma of vital organs, or stroke caused by vertebral artery injury were excluded from the study.
Results
: Out of 243 patients with CSCI, 30 required MV during their hospital stay, and 27 met the inclusion criteria. Among them, 48.1% (13/27) of patients had MVDC with greater than 30 days MV or death caused by aspiration pneumonia. In total, 51.9% (14/27) of patients could be weaned from MV during 30 days or less of hospital stay (MV days : MVDC 38.23±20.79 vs. MV weaning, 13.57±8.40; p<0.001). Vital signs at hospital arrival, smoking, the American Society of Anesthesiologists classification, Associated injury with Injury Severity Score, SLIC score, and length of cord edema did not differ between the MVDC and MV weaning groups. The ASIA impairment scale, level of injury within C3 to C6, and MCC significantly affected MVDC. The MCC significantly correlated with MVDC, and the optimal cutoff value was 51.40%, with 76.9% sensitivity and 78.6% specificity. In multivariate logistic regression analysis, MCC >51.4% was a significant risk factor for MVDC (odds ratio, 7.574; p=0.039).
Conclusion
: As a method of predicting which patients would be able to undergo weaning from MV early, the MCC is a valid factor. If the MCC exceeds 51.4%, prognosis of respiratory function becomes poor and the probability of MVDC is increased.

Keyword

Magnetic resonance imaging; Ventilators, Mechanical; Neck injuries; Respiratory insufficiency; Spinal injuries

Figure

  • Fig. 1. Measurement of MCC and length of cord edema. Midsagittal T2-weighted magnetic resonance imaging with acute traumatic cervical spinal cord injury. Left : MCC = (1 – Di(Da+Db)/2) × 100%, Di : the anteroposterior canal diameter at the level of maximum injury, Da : the anteroposterior canal diameter at the nearest normal level above the level of injury, Db : the anteroposterior canal diameter at the nearest normal level below the level of injury. Right : Length of cord edema or sum of cord signal change level. It is measured by the distance from the most cephalic extent A to the most caudal extent B of the injury. MCC : maximum canal compromise.

  • Fig. 2. Receiver operating characteristic curve for mechanical ventilator at hospital discharge. Cutoff value of MCC was 51.40% with sensitivity 0.769 and specificity 0.786 (p=0.020; 95% confidence interval, 0.576–0.952). MCC : maximum canal compromise.

  • Fig. 3. Kaplan-Meier curve for prediction of MV weaning. MV weaning (=0) and MVDC (=1) (p=0.004, log rank test [Mantel-Cox]). MV : mechanical ventilator, MCC : maximum canal compromise.


Reference

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